The concept that spinal manipulation therapy (SMT) outcomes are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use (candidate sites). This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere (non-candidate sites). Eligible study designs were randomized controlled trials that investigated the effect of spinal manipulation applied to candidate versus non-candidate sites for spinal pain. We obtained data from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. We extracted between-group differences for any reported outcome or, when not reported, calculated effect sizes from the within-group changes. We compared outcomes for SMT applied at a ‘relevant’ site to SMT applied elsewhere. We prioritized methodologically robust studies when interpreting results. Ten studies, all of acceptable quality, were included that reported 33 between-group differences—five compared treatments within the same spinal region and five at different spinal regions. None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI − 1.9 to − 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.

The mechanisms underlying pain relief following spinal manipulative therapy (SMT) are not understood fully although biomechanical and neurophysiological processes have been proposed. As such, we designed this randomized trial to elucidate the contributions of biomechanical and neurophysiological processes. A total of 132 participants with low back pain were randomly assigned to receive SMT at either the lumbar segment measured as the stiffest or the segment measured as having the lowest pain threshold. The primary outcome was patient reported low back pain intensity following treatment. Secondary outcomes were biomechanical stiffness and neurophysiological pressure pain threshold. All outcomes were measured at baseline, after the fourth and final session and at 2-weeks follow-up. Data were analyzed using linear mixed models, and demonstrated that the SMT application site did not influence patient reported low back pain intensity or stiffness. However, a large and significant difference in pressure pain threshold was observed between groups. This study provides support that SMT impacts neurophysiological parameters through a segment-dependent neurological reflex pathway, although this do not seem to be a proxy for improvement. This study was limited by the assumption that the applied treatment was sufficient to impact the primary outcome.

Background: Social media has become an increasingly important tool in monitoring the onset and spread of infectious diseases globally as well monitoring the spread of information about those diseases. This includes the spread of misinformation, which has been documented within the context of the emerging COVID-19 crisis. Understanding the creation, spread and uptake of social media misinformation is of critical importance to public safety. In this descriptive study, we detail Twitter activity regarding spinal manipulative therapy (SMT) and claims it increases, or “boosts”, immunity. Spinal manipulation is a common intervention used by many health professions, most commonly by chiropractors. There is no clinical evidence that SMT improves human immunity. Methods: Social media searching software (Talkwalker Quick Search) was used to describe Twitter activity regarding SMT and improving or boosting immunity. Searches were performed for the 3 months and 12 months before March 31, 2020 using terms related to 1) SMT, 2) the professions that most often provide SMT and 3) immunity. From these searches, we determined the magnitude and time course of Twitter activity then coded this activity into content that promoted or refuted a SMT/immunity link. Content themes, high-influence users and user demographics were then stratified as either promoting or refuting this linkage. Results: Twitter misinformation regarding a SMT/immunity link increased dramatically during the onset of the COVID crisis. Activity levels (number of tweets) and engagement scores (likes + retweets) were roughly equal between content promoting or refuting a SMT/immunity link, however, the potential reach (audience) of tweets refuting a SMT/immunity link was 3 times higher than those promoting a link. Users with the greatest influence on Twitter, as either promoters or refuters, were individuals, not institutions or organizations. The majority of tweets promoting a SMT/immunity link were generated in the USA while the majority of refuting tweets originated from Canada. Conclusion: Twitter activity about SMT and immunity increased during the COVID-19 crisis. Results from this work have the potential to help policy makers and others understand the impact of SMT misinformation and devise strategies to mitigate its impact.

Musculoskeletal pain is a major cause of work disability. Many patients with musculoskeletal pain seek care from health care providers other than their general practitioners, including a range of musculoskeletal practitioners. Therefore, these musculoskeletal practitioners may play a key role by engaging in sickness absence management and work disability prevention. This study aimed to determine the prevalence of musculoskeletal practitioners’ practice behaviours, and their perceptions and beliefs about sickness absence management by using Scandinavian chiropractors as an example, as well as to examine the association between these characteristics and two different practice behaviours. As part of a mixed-methods study, we surveyed members of the national chiropractic associations in Denmark, Norway, and Sweden in 2016. Descriptive statistics were used to describe prevalence. Multilevel logistic regression with backwards stepping was used to estimate odds ratios with 95% confidence intervals between each of the two practice behaviours and the characteristics. Out of the 802 respondents (response rate 56%), 372 were Danish, 349 Norwegian, and 81 Swedish. In Denmark and Norway, 38.7 and 37.8% always/often considered if sick leave was appropriate for their patient compared to 21.0% in Sweden (p = 0.007); and 86.5% of the Norwegian chiropractors always/often recommended to return-to-work versus 64.5 and 66.7% in Denmark and Sweden respectively (p < 0.001). In the final models, factors associated with the two practice behaviours were age, level of clinical experience, working as a teacher, the tendency to be updated on current legislations and policies using social services, contact with general practitioners, relevance of engagement in SAM, consideration of workplace factors, SAM as part of the clinical tool box, patient out-of-pocket fee, and recommending fast return-to-work. Whilst not always engaged in sickness absence management with regards to musculoskeletal pain, chiropractors favour a ‘return-to-work’ rather than a ‘stay-at-home’ approach. Several practice behaviours and perceptions and beliefs are associated with these outcomes; however, system or organisational barriers are linked to clinician non-engagement.

Background and aims: The choice of testing site for quantitative sensory testing (QST) of pain sensitivity is important and previous studies have demonstrated patterns in pain sensitivity within discrete areas in different body regions. Some areas are characterized by a relatively high degree of spatial pain discrimination and recognizable patterns of pain referral, whilst others are not. The lumbar region is likely to have relatively low pain acuity and overlapping of pain referral. The current study was conducted to determine whether patterns of pain sensitivity (detection thresholds) could be identified in the lower back, whether differences in such patterns exist between different groups and whether such patterns could help identify a clinical source of pain and localized increased pain sensitivity. Methods: Twenty-one patients with non-specific chronic low back pain and 21 healthy controls were tested for pressure and heat pain thresholds on 30 pre-defined locations over the mid and lower back. Topographical maps of mean pain thresholds and variability were produced, inspected visually and analyzed statistically. Between group differences in pain threshold were analyzed statistically as an indicator of widespread increased pain sensitivity. Evidence of segmental increased pain sensitivity was examined by group statistical comparison of mid-line lower range. Results: A clear pattern of higher pain thresholds in the mid-line was evident in both groups and for both pain modalities. No discernible patterns were evident for variability within groups, but marked differences were seen between groups: variability for pressure pain thresholds appeared similar between groups, however for heat pain threshold, variability was uniformly low in the control group and uniformly high in the patient group. A highly significant ( p 0.05). Conclusions: The current study supports previous findings of widespread, increased pain sensitivity in chronic non-specific low-back pain patients. It also indicates that there are discernible and similar topographical patterns of pain sensitivity in the dorsal area in both groups, but that this pattern is related to the lateral position of the test site and not the segmental level. Specific segments with increased pain sensitivity could not be identified in the patient group, which casts doubt on the utility of pressure and heat pain thresholds as indicators of the clinical source of spinal pain – at least in a population of chronic non-specific low-back pain. Implications: In a cohort of chronic non-specific low-back pain patients and with the chosen methodology, topographical QST mapping in the lumbar region does not appear useful for identifying the spinal segment responsible for clinical pain, but it does demonstrate widespread group differences in pain sensitivity.

Force-Based Manipulation (FBM) including light touch, pressure, massage, mobilization, thrust manipulation, and needling techniques are utilized across several disciplines to provide clinical analgesia. These commonly used techniques demonstrate the ability to improve pain-related outcomes; however, mechanisms behind why analgesia occurs with these hands-on interventions has been understudied. Neurological, neuroimmune, biomechanical, neurovascular, neurotransmitter, and contextual factor interactions have been proposed to influence response; however, the specific relationships to clinical pain outcomes has not been well established. The purpose of this study was to identify gaps present within mechanism-based research as it relates to FBM. An international multidisciplinary nominal group technique (NGT) was performed and identified 37 proposed gaps across eight domains. Twenty-three of these gaps met consensus across domains supporting the complex multisystem mechanistic response to FBM. The strength of support for gaps within the biomechanical domain had less overall support than the others. Gaps assessing the influence of contextual factors had strong support as did those associating mechanisms with clinical outcomes (translational studies). The importance of literature investigating how FBM differs with individuals of different pain phenotypes (pain mechanism phenotypes and clinical phenotypes) was also presented aligning with other analgesic techniques trending toward patient-specific pain management (precision medicine) through the use of pain phenotyping.